Journal of the Royal Society of Medicine Volume 85 May 1992
Critical ischaemia of the
M S Quraishy FRCS
upper
269
limb
S J Cawthorn FRCS
A E B Giddings MD FRCS
Department of Surgery,
Royal Surrey County Hospital, Guildford, Surrey GU2 5XX Keywords: ischaemia; upper limb; atheroma; arteritis; embolism
Summary Fifty-seven patients who presented to the Royal Surrey County Hospital, Guildford, with critical upper limb ischaemia between 1980 and 1989 were studied. Only 13 patients had emboli, while 23 presented with arteritis, seven involving large vessels and 16 with small vessel disease. Other causes included nine patients with trauma, six with atherosclerosis (of whom five were women), and four with vascular complications of thoracic outlet obstruction. Single examples of ischaemia due to radiation fibrosis and disseminated intravascular coagulation were also seen. Critical ischaemia of the upper limb remains an uncommon yet challenging problem. The review demonstrates that total limb arteriography should be performed in all patients, except the minority who present with direct arterial trauma or classical emboli. Introduction Critical ischaemia presents in the upper limb much less commonly than in the lower limb and affects females more than males. Disability is common but limb loss is rare'. In this district, less than -2% of patients who required admission for symptoms of rest pain, gangrene or ulcer sepsis,- were suffering from arm ischaemia. While atherosclerosis is the predominant pathology in the leg, this condition is responsible for only a minority of those with ischaemic arms, in whom arteritis, systemic embolism and trauma are more frequent. The differential diagnosis requires careful clinical evaluation and radiological assessment2. Since 1980, we have followed the policy of complete upper limb arteriography in all patients with critical ischaemia of the arm who do not also have the classical acute symptoms and cardiac signs of systemic embolism or direct arterial trauma. The management repertoire for the treatment of these patients is wide and the indication for vasoactive drugs, steroids, bypass, embolectomy, endarterectomy, thrombolysis, decompression ofthe thoracic outlet and sympathectomy by open or endoscopic methods are not well defined. This review was undertaken to audit current practice, to define more closely the indications for arteriography and surgery, and to examine the potential for the replacement of arteriography by noninvasive diagnostic methods. Patients and methods Details ofthe presentation, investigation and -management of 57 patients who required admission to the Correspondence to: Mr A E B Giddings, Department of Surgery, Royal Surrey County Hospital, Guildford, Surrey GU2 5XX
Royal Surrey County Hospital, Guildford, due to Paper read to critical ischaemia of the upper limb, (defined as the Section of presence of rest pain, ulcer sepsis or gangrene), were Surgery, obtained from the admission summaries, copies of 5 May 1989 which were retained by the Vascular Firm. These were checked against Hospital Activity Analysis records, theatre and radiological records. Details are shown in Tables 1-6. Over 9 years from 1980, 57 patients presented between the ages of 17 and 85 years; 43 were female. They were divided into diagnostic groups, arteritis (23), systemic embolism (13), atherosclerosis (6), trauma (9), thoracic outlet syndrome (4), and miscellaneous (2). In 12, the diagnosis of classical embolism from the heart was made clinically and no arteriography was performed. Similarly, with the patients who had obvious direct arterial trauma, operation was undertaken without previous arteriography. In all other patients, arteriography proved essential in diagnosis. Results Systemic embolism (Table 1) Thirteen patients had emboli originating from the heart. They were aged between 57 and 85 years and 10 were female. Ten were in atrial fibrillation, one in congestive heart failure and one had a dilated ventricle with mural thrombus shown by echocardiography. None ofthese 12 underwent arteriography. The 13th patient- was a 73-year-old woman in whom arteriography was undertaken because, in addition to her ischaemic right hand, she developed weakness in her well-perfused left arm. Arteriography showed extensive embolic occlusions in her right subclavian and common carotid arteries and she was managed by anticoagulation. Her right arm improved but the neurological weakness in her left arm remained unchanged. Arteritis (Table 2) Of 23 patients, aged 23-75 years, with arteritis, all seven with large vessel disease were female, while the 16 digital vessel disease patients included four males. Of the seven with large vessel arteritis, five showed changes in the subclavian vessels, three bilaterally (one metachronous). The diagnosis was usually delayed and the condition mistaken for musculoskeletal pain in the early stages. Symptoms were usually aching in the shoulder girdle, particularly at night. Three of the five, however, also had arm claudication and one presented with cyanosis and digital ulceration. Only four ofthe seven had an ESR greater than 30 mm/h and one had hypochromic anaemia. In all patients, upper limb arteriography was diagnostic3 and all were initially managed with steroids. Their systemic symptoms were improved
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Journal of the Royal Society of Medicine Volume 85 May 1992
Table 1. Systemic embolization
Diagnosis
Treatment
Arteriography
Classical emboli (3 male, 9 female) Atrial fibrillation 10 None 1 Congestive cardiac failure 1 Ventricular aneurysm Non-classical embolus (1 female) Stroke-in-evolution
Anticoagulation Embolectomy Brachial Brachial and subclavian Deaths
Embolic occlusion of subclavian and common carotid arteries
Anticoagulation Completed stroke
Arteriography
Treatment
3 10 9 1 2
Table 2. Arteritis
Diagnosis
Large vessel (7 female) 5 Diagnostic Subclavian/axillary (bilateral 3) Brachial 1 Ulnar 1 Small vessel (4 male, 12 female) 6 Diagnostic of spastic and/or fixed obstruction Idiopathic Connective tissue disorders 10 (scleroderma 4)
within a few days (loss of shoulder girdle pain being dramatic), but in two patients continued distal ischaemic symptoms led to surgical exploration, thrombectomy and biopsy. Histology of the biopsies confirmed the diagnosis of arteritis. One of these patients subsequently also underwent transaxillary sympathectomy, the remaining six being controlled by steroids. None required surgical bypass. Case report A 43-year-old woman presented with claudication in her left arm. Her brachial pulse was absent and arteriography demonstrated multiple arteritic strictures of her left subclavian artery. Treatment with steroids improved her symptoms but, several weeks later as the dose was reduced, she developed identical symptoms in the right arm. Repeat arteriography then showed progressive arteritic stricturing of the right subclavian vessel. Her symptoms again responded to high-dose prednisolone (40 mg/day), and did not recur when the dose was reduced to a maintenance level of 5 mg/day.
Ofthe 16 patients who presented with digital vessel arteritis, six had severe Raynaud's syndrome without
Steroids Thrombectomy and biopsy Transaxillary sympathectomy
Transaxillary sympathectomy and debridement 4 4 Debridement 1 Digital amputation
systemic disease, and four of these were critical, thus justifying transaxillary sympathectomy; all four experienced some symptomatic benefit and, on prolonged follow-up, did not require any further treatment. Ten patients had connective tissue disorders, of which four had scleroderma and, of these, three needed surgical debridement. The remaining patients with connective tissue disorders were treated with steroids and two also with azathioprine. Five had a good response but the sixth required cyclophosphamide and transaxillary sympathectomy. Despite these treatments, gangrene progressed
despital
tatmen
gangrene
Trauma (Table 3) Only in this group of nine patients do males predominate (6: 3). They are divided into two categories,
sion a -le ln at the site injury, indicating ~~~~~~~direct artenlal of trauma, and remote arterial injury, where traction i
n
on a blood vessel induces an avulsion injury to the vessel or its branches at a site remote from the obvious
Arteriography
Direct arterial trauma (5 male, 2 female) 2 None Penetrating Blunt trauma 1 None 1 None Sharp trauma Fractured clavicle 2 None
Brachial catheter 1 Long occlusion Remote arterial trauma (1 male, 1 female) 1 Traction injury at shoulder, good collaterals Supracondylar fracture'
Treatment
Local repair Vein graft Local repair Local repair Conservative Thrombectomy, vein patch
Bony fixation, nerve repair, conservative
Dislocated shoulder
this
patient.
Table 3. Trauma
Diagnosis
7 2 1
1 Traction injury, good collaterals
Conservative
Journal of the Royal Society of Medicine Volume 85 May 1992 Table 4. Atherosclerosis (one male, five female)
Treatment
Arteriography
Diagnosis
Subclavian
3 Occlusion
Axillary and subclavian Axillary Generalized
1 Stricture and ulceration 1 Stenosis 1 Multiple blocks
bony or soft tissue damage. Remote arterial injury requires arteriographic diagnosis4. Atherosclerosis (Table 4) Six patients had the history of acute-on-chronic ischaemia and the arteriographic signs were those of atherosclerosis. The patients were aged between 42 and 82 years, but only one was male. In three patients there was an occlusion of the subclavian artery, while in one the axillary artery only was involved. The sixth patient had diffuse changes throughout the upper limb. Thoracic outlet syndrome (Table 5) Four patients suffered chronic ischaemia as a result of thoracic outlet compression. All were women, from 20 to 71 years old. Two underwent thoracic outlet decompression alone, but the other two required multiple procedures. One had progressive ischaemia of her dominant right hand due to micro-emboli which had arisen on an ulcerated stricture in the subclavian artery. This was treated by excision ofthe compressing rib, endarterectomy and subsequent transaxillary sympathectomy. The fourth patient presented with acute arm ischaemia and atrial fibrillation: initially, a diagnosis of systemic embolism was made and embolectomy undertaken by a supracondylar approach, without arteriography of the proximal vessels. The early result was satisfactory but the occlusion recurred one week later. Arteriography then showed arching of the artery around a cervical rib, with an intimal irregularity in that area. Thrombolysis, using a standard protocol5, was unsuccessful and we would not generally advocate this management of occlusive disease in the upper limb, because of the risks of proximal pericatheter clot formation and cerebral embolization. Removal of the cervical rib and embolectomy brought little benefit and a third arteriogram was required to confirm that the proximal artery was now normal but there was persistent clot below the elbow. Finally, an embolectomy from the elbow gave a good result. Miscellaneous This group consisted of two female patients. The first underwent axillo-axillary bypass to treat fibrotic
2 Axillo-axillary bypass 1 Conservative Endarterectomy (failed) and bypass Endarterectomy and sympathectomy None
ischaemia of the subclavian artery following radiotherapy for carcinoma of the breast, and the second developed widespread arterial thrombosis in her arm due to disseminated intravascular coagulation (DIC), secondary to post-cholecystectomy sepsis. In her case also, thrombolysis was attempted, without success, and due to occlusion of all potential collaterals, gangrene and amputation followed. Her rehabilitation, however, was excellent. Discussion
Critical ischaemia is much less common in the upper limb than in the lower limb, accounting for only 5% of peripheral vascular cases1, yet there are many causes. Diagnosis requires careful clinical and radiological assessmentl"2'6-'0 but, unlike the lower limb, the role of non-invasive methods in diagnosis is not well established. Clinical evaluation should include a history of accidental or occupational trauma; sudden ischaemia in the presence of atrial fibrillation suggests embolization. A significant number of patients with a connective tissue disorder will present with systemic symptoms. These may be local, for example aching in the shoulder girdle due to subclavian arteritis, or distal, due to the effects of ischaemia. Non-invasive laboratory studies are a useful adjunct to confirm clinical assessment, but arteriography7 remains the 'gold standard'. Doppler ultrasound and digital arterial pressure recordings confirm the degree of ischaemia and are useful to monitor change, but they do not demonstrate the cause of the ischaemia. For this, total extremity arteriography, sometimes including magnification, subtraction and cryodynamic techniques", may all be useful. Porter and his colleagues have reported the use of digital plethysmography to replace arteriography 'unless a surgically correctable lesion is suspected' 12, but this begs the question of how that suspicion would be aroused unless the vascular anatomy can be shown. Most emboli to the upper limb present with classical symptoms'3. They account for only 10-15% of all peripheral emboli'4"15, but the outcome is better than in the lower limb'6. Success in treatment depends on early diagnosis and anticoagulation'3. Embolectomy
Table 5. Thoracic outlet syndrome (four females)
Diagnosis
Arteriography
Treatment
Fibrous band Cervical rib, subclavian ulcer, distal emboli Bilateral cervical ribs Atrial fibrillation and cervical rib
Compression Proximal lesion and distal occlusions
Division of band Excision of rib, endarterectomy and sympathectomy Excision of ribs Embolectomy, thrombolysis, resection of rib, subclavian and brachial embolectomy
Bilateral compression Embolus, cervical rib stenosis and debris at elbow
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Journal of the Royal Society of Medicine Volume 85 May 1992
from an antecubital approach can be expected to produce a good result within the first 12 hours, as may be seen in these 12 patients, and there is a place for delayed surgery (up to five days) in those with adequate collateral vessels17. Anticoagulation is usually recommended to counter the risks of further emboli which may threaten up to a third of the patients6 and is associated with a high mortality. Both early and late surgery have been shown to be superior to anticoagulation alone'8. Arteriography was not required in these 12 classically-presenting patients but was undertaken in the patient who presented with a 'stroke in evolution', as well as an ischaemic arm; when clot had been demonstrated in both subclavian and common carotid arteries, she was managed by anticoagulation alone. While arteriography is not essential for the management of classical emboli, other symptoms require arteriographic diagnosis. Several names have been given to vasculitis affecting large vessels19, 'pulseless disease', Takayasu's disease or brachio-cephalic arteritis20. Both the aorta and its branches may be affected, including the renal artery21. The cause is unknown but an association with HLA-BW52 in Japan22, and MB3-DR4 histocompatibility antigens in the USA23, has been described. Large peripheral arteries may also be involved in patients with giant cell arteritis2A, which results in thickening due to proliferation of connective tissue, and an inflammatory cell infiltrate with multinucleate giant cells. The internal elastic lamina is disrupted and medial fibrosis and intimal damage lead to thrombosis, aneurysm and dissection. Symptoms result both from the local effects of inflammation, such as an aching shoulder, or from regional effects due to arm ischaemia. Angiographic signs include multiple long strictures3 which may improve with steroids. Surgery is reserved for the relief of severe obstruction25 26. Surgical procedures for unrelieved obstruction have been reviewed recently19, but the results are poor20 when compared to those for occlusive disease due to atheroma25. The value of complete arteriography from the thoracic outlet to the finger-tips is emphasized, since lesions may be shown at several sites20. The poor long-term results of sympathectomy for vasospastic symptoms, with a relapse rate of 77% from 1 to 7 years27'28, have restricted its use here to severe digital ischaemia in those in whom the obstruction has been fixed despite intra-arterial tolazoline. Porter12 has suggested that all of these patients have occult systemic disease. Of the 16 patients in this series who suffered small vessel arteritis, ten were shown to have an underlying connective tissue disorder. Porter and his colleagues have also reviewed the medical treatment of Raynaud's syndrome, confirming that treatment is less effective when fixed digital occlusions are shown, for example, by cryodynamic imaging. Treatment with prostaglandins29, the fibrinolytic-stimulating drug, stanazolol30, and plasmaphoresis31, have also been tried, but long-term benefit has not been proved. In this series, four of the six patients with idiopathic Raynaud's syndrome and fixed blocks responded well to transaxillary sympathectomy. Those with known underlying connective tissue disorders were also treated with steroids and azathioprine (2), with some improvement. One patient required digital amputation. The management of direct trauma has been well documented7'32, and five of the seven cases in this
series were successfully managed by local repair. Techniques used were resection and end-to-end anastomosis, thrombectomy, vein patch and repair of intimal dissection. Only one patient with direct arterial trauma needed arteriography, due to the late presentation of a long occlusion after cardiac catheterization. He underwent thrombectomy, with repair of the damaged vessel wall, because of disabling arm claudication, which is known to follow such injuries in up to 70% of patients, particularly if wrist pressure indices are reduced to half on exercise33 3. Conservative treatment alone will, however, usually be sufficient to prevent limb loss3. Paraesthesiae may persist, despite arterial repair, due to ischaemic nerve damage33. The problem of arterial injury remote from the site of trauma4 may easily be overlooked, even in comprehensive reviews, and presents significant difficulty in diagnosis. Of the two patients described here, one had a dislocated shoulder with a closed traction injury to the root of the neck. Arteriography showed that the subclavian artery was occluded but there was no bleeding and a good collateral circulation was seen; he was, therefore, managed conservatively. Such lesions may present late35, and successful conservative treatment depends on safe, early heparinization4. In the other case, arteriography demonstrated the lesion remote from the site of bony fracture, thus avoiding fruitless blind exploration. Atherosclerosis is generally more common in men36, but in the upper limb more women than men are affected; in this series, five ofthe six patients were female. The surgical treatment is well described'9, including endarterectomy and bypass. Extra-thoracic bypass is preferred, since this is safer than intrathoracic procedures37. Sympathectomy may be helpful when reconstruction is not practicable19. Vascular complications may develop in 10-20% of patients with thoracic outlet syndrome19. Compression of the subclavian artery between the first rib, the scalenus anterior muscle and a cervical rib may result in medial degeneration, with intimal hyperplasia, stenosis and post-stenotic dilatation. Distal embolization causes progressive digital ischaemia. Full arteriography should be performed and, if negative, should be repeated. This was necessary in one of these patients before the source of the emboli could be identified. On-table arteriography has been used, but the results should be interpreted with caution due to the frequency of spasm in the upper limb vessels. When the arteriogram is negative and there is a high index of suspicion9, blind exploration has been advised, but surgical access is difficult and every effort must be made to show the lesion preoperatively. Treatment ofthe proximal lesion and resection ofthe band is helpful in preventing further emboli9, but distal blocks are more difficult, as anastomosis between digital vessels is very limited. Sympathectomy may help to improve viability and control pain. Two patients were placed in the miscellaneous group. The first showed the value of axillo-axillary bypass for the ischaemic post-radiation stricture, when this simple procedure can be carried out while avoiding the irradiated field38. The second patient, who developed thrombosis of the vessels of her left arm, due to DIC, was diagnosed late due to the effects of shock on all her limbs. It was only on resuscitation that the diagnosis of local thrombosis in one limb was made.
Journal of the Royal Society of Medicine Volume 85 May 1992
This review has confirmed that, with the exception of classical emboli and direct open trauma, all patients with critical arm ischaemia require total limb arteriography. Duplex ultrasound scanning and pressure studies are useful and might even replace arteriographic diagnosis in the leg39. However, difficulties in Doppler examination of upper limb vessels and the wide spectrum of pathology responsible for ischaemia of the arm, suggest that arteriography is unlikely to be replaced by non-invasive methods in the foreseeable future. Fifty-seven patients with critical upper limb ischaemia were treated in a community hospital, serving a population of 200 000 people, over a period of nine years. Although uncommon, critical upper limb ischaemia remains a challenging problem with a diverse aetiology. To identify t-he cause and to plan and execute treatment, total limb arteriography should be performed in allpatients except those who present with obvious direct trauma and classical systemic embolism. Digital subtraction angiography, pressure studies and Duplex scanning may be helpful but cannot replace arteriography. References 1 Welling RE, Cranley JJ, Krause RJ, Hafner CD. Obliterative arterial disease of the upper extremity. Arch Surg 1981;116:1593-5 2 McNamara MF, Takaki HS, Yao JST, Bergan JJ. A systemic approach to severe hand ischaemia. Surgery 1978;83:1-11 3 Sano K, Aiba T, Saito I. Angiography in pulseless disease. Radiology 1970;94:69-74 4 Yanni D, Wetzig NR, Giddings AEB. Remote arterial injury; another cause of spunous'arterial spasm. J Cardiovasc Surg 1989;30:948-50 5 Walker WJ, Giddings AEB. A protocol for the safe treatment of acute lower limb ischaemiawith intra-arterial streptokinase and surgery. Br JSurg 1988;75:1189-92 6 Ricotta JJ, Scudder PA, McAndrew JA, DeWeese JA, May AG. Management of acute ischaemia of the upper extremity. Am J Surg, 1983;145:661-6 7 Jarrett F, Hirsch SA.' Current diagnosis and management of upper extremity ischaemia. Surg Ann 1984; 15:207-28 8 Schmidt FE, Hewitt RL. Severe upper limb ischaemia. Arch Surg 1980;115:1188-91 9 Whelan TJ. Management of vascular disease of the upper extremity. Surg Clin North Am 1982;62:373-88 10 Keenan JP, Robbs JV. The ischaemic hand and upper limb - a diagnostic and therapeutic dilemma. S Afr J Surg 1985;23:11-14 11 Rosch J, Porter JM, Gralino BJ. Cryodynamic hand angiography in the diagnosis and management of Raynaud's syndrome. Circulation 1977;55:807-14 12 Porter JM, Rivers SP, Anderson CJ, Bauer GM. Evaluation and management of patients with Raynaud's syndrome. Am J Surg 1981;142:183-9 13 Kaar G, Broe PJ, Bouchier-Hayes DJ. Upper limb emboli. J Cardiovasc Surg 1989;30:165-8 14 Hight DW, Tilney NL, Crouch NP. Changing clinical trends in patients with peripheral arterial emboli. Surgery 1976;79:172-6 15 Satiani B, Gross WS, Evans WE. Improved limb salvage after arterial embolectomy. Ann Surg 1978;188: 153-7 16 Stonebridge PA, Clason AE, Duncan AJ, Nolan B,
Jenkins AMcL, Ruckley CV. Acute ischaemia of the upper limb compared with acute lower limb ischaemia; a 5-year review. Br J Surg 1989;76:515-16
17 Jarrett F, Dacumos GC, Crummy AB, Detmer DE, Belzer FO. Late appearance of arterial emboli: diagnosis and management. Surgery 1979;86:898 18 Baird RJ, Lajos TZ. Emboli to the arm. Ann Surg 1964;160:905-9 19 Williams SJ. Chronic upper extremity ischaemia: current concepts in management. Surg Clin North Am 1986;66:355-75 20 Cohen A, Manion WC, Spencer FC, et aL Occlusive lesions ofthe great vessels ofthe aortic arch. Arch Surg 1962;84:628-42 21 Sise MJ, Counihan CM, Shackford SR, Rowley WR. The clinical spectrum of Takayasu's arteritis. Surgery 1988;104:905-10 22 Isohisa I, Numano F, Maezawa H, Sasazuki T. HLABW52 in Takayasu's disease. Tissue Antigens 1978; 12:246-8 23 Volkman DJ, Mann DL, Fauci AS. Association between Takayasu's arteritis and a B-cell allo-antigen in North Americans. N Engl J Med 1982;306:464-5 24 Klein RG, Hunder CG, Stanson AW, Sheps SG. Large artery involvement in giant-cell (temporal) arteritis. Ann Intern Med 1975;83:806-12 25 McCarthy WJ, Flinn WR, Yao JST, Williams LR, Bergan JJ. Result of bypass grafting for upper limb ischaemia. J Vasc Surg 1986;3:741-6 26 Joyce JW. The giant-cell arteritides: diagnosis and the role of surgery. J Vasc Surg 1986;3:827-33 27 Hall XV, Hillstad LK. Raynaud's phenomenon treated with sympathectomy: a follow-up study. Angiology 1960;11:186-9 28 van de Wal HJCM, Skotnicki SH, Wijn PFF, Lacquet LK. Thoracic sympathectomy as a therapy for upper extremity ischaemia - a long-term follow-up study. Thorac Cardiovasc Surg 1985;33:181-7 29 Clifford PC, Martin MFR, Shedden EJ, Kirby JD, Baird RN, Dieppe PA. Treatment of vasospastic disease with prostaglandin E1. BMJ 1980;ii:1031-4 30 Jarrett PEM, Morland M, Browse NL. Treatment of Raynaud's phenomenon by fibrinolytic enhancement. BMJ 1978;ii:523-5 31 Talpos G, White JM, Horrocks M, Cotton LT. Plasmaphoresis in Raynaud's disease. Lancet 1978;i:416-18 32 Blacklay PF, Duggan E, Wood RFM. Vascular trauma. Br J Surg 1987;74:1077-83 33 Karmody AM, Lempert N, Jarmolych J. The pathology of post-catheterisation brachial artery occlusion. J Surg Res 1976;20:601-4 34 rammarher ER, Eikelboom BC, van Lier HJJ, Skotnicki SH, Wijn PFF. Brachial artery lesions after cardiac catheterisation. Eur J Vasc Surg 1988;2:145-9 35 Stanton PE(Jr), Brown R, Rosenthal D, Clark M, Lamis PA. External iliac artery occlusion by bicycle handle injury. J Cardiovasc Surg 1986;27:728-30 36 Gordon RD, Garrett HE. Atheromatous and aneurysmal disease of upper extremity arteries. In: Rutherford RB, ed. Vascular surgery. Philadelphia: WB Saunders Co, 1984:688-93 37 Crawford ES, DeBakey ME, Morris GC, et al. Surgical treatment ofocclusion ofthe innominate common carotid and subclavian arteries: a 10 year experience. Surgery
1969;65:17-31 38 Butler MJ, Lane RHS, Webster JHN. Irradiation injury to large arteries. Br J Surg 1980;67:341-3 39 Cossman DV, Ellison JE, Wagner WH, et aL Comparison of contrast arteriography to arterial mapping with colorflow duplex imaging in the lower extremities. J Vasc Surg 1989;1O:522-9
(Accepted 14 August 1991)
273
Critical ischaemia of the
M S Quraishy FRCS
upper
269
limb
S J Cawthorn FRCS
A E B Giddings MD FRCS
Department of Surgery,
Royal Surrey County Hospital, Guildford, Surrey GU2 5XX Keywords: ischaemia; upper limb; atheroma; arteritis; embolism
Summary Fifty-seven patients who presented to the Royal Surrey County Hospital, Guildford, with critical upper limb ischaemia between 1980 and 1989 were studied. Only 13 patients had emboli, while 23 presented with arteritis, seven involving large vessels and 16 with small vessel disease. Other causes included nine patients with trauma, six with atherosclerosis (of whom five were women), and four with vascular complications of thoracic outlet obstruction. Single examples of ischaemia due to radiation fibrosis and disseminated intravascular coagulation were also seen. Critical ischaemia of the upper limb remains an uncommon yet challenging problem. The review demonstrates that total limb arteriography should be performed in all patients, except the minority who present with direct arterial trauma or classical emboli. Introduction Critical ischaemia presents in the upper limb much less commonly than in the lower limb and affects females more than males. Disability is common but limb loss is rare'. In this district, less than -2% of patients who required admission for symptoms of rest pain, gangrene or ulcer sepsis,- were suffering from arm ischaemia. While atherosclerosis is the predominant pathology in the leg, this condition is responsible for only a minority of those with ischaemic arms, in whom arteritis, systemic embolism and trauma are more frequent. The differential diagnosis requires careful clinical evaluation and radiological assessment2. Since 1980, we have followed the policy of complete upper limb arteriography in all patients with critical ischaemia of the arm who do not also have the classical acute symptoms and cardiac signs of systemic embolism or direct arterial trauma. The management repertoire for the treatment of these patients is wide and the indication for vasoactive drugs, steroids, bypass, embolectomy, endarterectomy, thrombolysis, decompression ofthe thoracic outlet and sympathectomy by open or endoscopic methods are not well defined. This review was undertaken to audit current practice, to define more closely the indications for arteriography and surgery, and to examine the potential for the replacement of arteriography by noninvasive diagnostic methods. Patients and methods Details ofthe presentation, investigation and -management of 57 patients who required admission to the Correspondence to: Mr A E B Giddings, Department of Surgery, Royal Surrey County Hospital, Guildford, Surrey GU2 5XX
Royal Surrey County Hospital, Guildford, due to Paper read to critical ischaemia of the upper limb, (defined as the Section of presence of rest pain, ulcer sepsis or gangrene), were Surgery, obtained from the admission summaries, copies of 5 May 1989 which were retained by the Vascular Firm. These were checked against Hospital Activity Analysis records, theatre and radiological records. Details are shown in Tables 1-6. Over 9 years from 1980, 57 patients presented between the ages of 17 and 85 years; 43 were female. They were divided into diagnostic groups, arteritis (23), systemic embolism (13), atherosclerosis (6), trauma (9), thoracic outlet syndrome (4), and miscellaneous (2). In 12, the diagnosis of classical embolism from the heart was made clinically and no arteriography was performed. Similarly, with the patients who had obvious direct arterial trauma, operation was undertaken without previous arteriography. In all other patients, arteriography proved essential in diagnosis. Results Systemic embolism (Table 1) Thirteen patients had emboli originating from the heart. They were aged between 57 and 85 years and 10 were female. Ten were in atrial fibrillation, one in congestive heart failure and one had a dilated ventricle with mural thrombus shown by echocardiography. None ofthese 12 underwent arteriography. The 13th patient- was a 73-year-old woman in whom arteriography was undertaken because, in addition to her ischaemic right hand, she developed weakness in her well-perfused left arm. Arteriography showed extensive embolic occlusions in her right subclavian and common carotid arteries and she was managed by anticoagulation. Her right arm improved but the neurological weakness in her left arm remained unchanged. Arteritis (Table 2) Of 23 patients, aged 23-75 years, with arteritis, all seven with large vessel disease were female, while the 16 digital vessel disease patients included four males. Of the seven with large vessel arteritis, five showed changes in the subclavian vessels, three bilaterally (one metachronous). The diagnosis was usually delayed and the condition mistaken for musculoskeletal pain in the early stages. Symptoms were usually aching in the shoulder girdle, particularly at night. Three of the five, however, also had arm claudication and one presented with cyanosis and digital ulceration. Only four ofthe seven had an ESR greater than 30 mm/h and one had hypochromic anaemia. In all patients, upper limb arteriography was diagnostic3 and all were initially managed with steroids. Their systemic symptoms were improved
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Journal of the Royal Society of Medicine Volume 85 May 1992
Table 1. Systemic embolization
Diagnosis
Treatment
Arteriography
Classical emboli (3 male, 9 female) Atrial fibrillation 10 None 1 Congestive cardiac failure 1 Ventricular aneurysm Non-classical embolus (1 female) Stroke-in-evolution
Anticoagulation Embolectomy Brachial Brachial and subclavian Deaths
Embolic occlusion of subclavian and common carotid arteries
Anticoagulation Completed stroke
Arteriography
Treatment
3 10 9 1 2
Table 2. Arteritis
Diagnosis
Large vessel (7 female) 5 Diagnostic Subclavian/axillary (bilateral 3) Brachial 1 Ulnar 1 Small vessel (4 male, 12 female) 6 Diagnostic of spastic and/or fixed obstruction Idiopathic Connective tissue disorders 10 (scleroderma 4)
within a few days (loss of shoulder girdle pain being dramatic), but in two patients continued distal ischaemic symptoms led to surgical exploration, thrombectomy and biopsy. Histology of the biopsies confirmed the diagnosis of arteritis. One of these patients subsequently also underwent transaxillary sympathectomy, the remaining six being controlled by steroids. None required surgical bypass. Case report A 43-year-old woman presented with claudication in her left arm. Her brachial pulse was absent and arteriography demonstrated multiple arteritic strictures of her left subclavian artery. Treatment with steroids improved her symptoms but, several weeks later as the dose was reduced, she developed identical symptoms in the right arm. Repeat arteriography then showed progressive arteritic stricturing of the right subclavian vessel. Her symptoms again responded to high-dose prednisolone (40 mg/day), and did not recur when the dose was reduced to a maintenance level of 5 mg/day.
Ofthe 16 patients who presented with digital vessel arteritis, six had severe Raynaud's syndrome without
Steroids Thrombectomy and biopsy Transaxillary sympathectomy
Transaxillary sympathectomy and debridement 4 4 Debridement 1 Digital amputation
systemic disease, and four of these were critical, thus justifying transaxillary sympathectomy; all four experienced some symptomatic benefit and, on prolonged follow-up, did not require any further treatment. Ten patients had connective tissue disorders, of which four had scleroderma and, of these, three needed surgical debridement. The remaining patients with connective tissue disorders were treated with steroids and two also with azathioprine. Five had a good response but the sixth required cyclophosphamide and transaxillary sympathectomy. Despite these treatments, gangrene progressed
despital
tatmen
gangrene
Trauma (Table 3) Only in this group of nine patients do males predominate (6: 3). They are divided into two categories,
sion a -le ln at the site injury, indicating ~~~~~~~direct artenlal of trauma, and remote arterial injury, where traction i
n
on a blood vessel induces an avulsion injury to the vessel or its branches at a site remote from the obvious
Arteriography
Direct arterial trauma (5 male, 2 female) 2 None Penetrating Blunt trauma 1 None 1 None Sharp trauma Fractured clavicle 2 None
Brachial catheter 1 Long occlusion Remote arterial trauma (1 male, 1 female) 1 Traction injury at shoulder, good collaterals Supracondylar fracture'
Treatment
Local repair Vein graft Local repair Local repair Conservative Thrombectomy, vein patch
Bony fixation, nerve repair, conservative
Dislocated shoulder
this
patient.
Table 3. Trauma
Diagnosis
7 2 1
1 Traction injury, good collaterals
Conservative
Journal of the Royal Society of Medicine Volume 85 May 1992 Table 4. Atherosclerosis (one male, five female)
Treatment
Arteriography
Diagnosis
Subclavian
3 Occlusion
Axillary and subclavian Axillary Generalized
1 Stricture and ulceration 1 Stenosis 1 Multiple blocks
bony or soft tissue damage. Remote arterial injury requires arteriographic diagnosis4. Atherosclerosis (Table 4) Six patients had the history of acute-on-chronic ischaemia and the arteriographic signs were those of atherosclerosis. The patients were aged between 42 and 82 years, but only one was male. In three patients there was an occlusion of the subclavian artery, while in one the axillary artery only was involved. The sixth patient had diffuse changes throughout the upper limb. Thoracic outlet syndrome (Table 5) Four patients suffered chronic ischaemia as a result of thoracic outlet compression. All were women, from 20 to 71 years old. Two underwent thoracic outlet decompression alone, but the other two required multiple procedures. One had progressive ischaemia of her dominant right hand due to micro-emboli which had arisen on an ulcerated stricture in the subclavian artery. This was treated by excision ofthe compressing rib, endarterectomy and subsequent transaxillary sympathectomy. The fourth patient presented with acute arm ischaemia and atrial fibrillation: initially, a diagnosis of systemic embolism was made and embolectomy undertaken by a supracondylar approach, without arteriography of the proximal vessels. The early result was satisfactory but the occlusion recurred one week later. Arteriography then showed arching of the artery around a cervical rib, with an intimal irregularity in that area. Thrombolysis, using a standard protocol5, was unsuccessful and we would not generally advocate this management of occlusive disease in the upper limb, because of the risks of proximal pericatheter clot formation and cerebral embolization. Removal of the cervical rib and embolectomy brought little benefit and a third arteriogram was required to confirm that the proximal artery was now normal but there was persistent clot below the elbow. Finally, an embolectomy from the elbow gave a good result. Miscellaneous This group consisted of two female patients. The first underwent axillo-axillary bypass to treat fibrotic
2 Axillo-axillary bypass 1 Conservative Endarterectomy (failed) and bypass Endarterectomy and sympathectomy None
ischaemia of the subclavian artery following radiotherapy for carcinoma of the breast, and the second developed widespread arterial thrombosis in her arm due to disseminated intravascular coagulation (DIC), secondary to post-cholecystectomy sepsis. In her case also, thrombolysis was attempted, without success, and due to occlusion of all potential collaterals, gangrene and amputation followed. Her rehabilitation, however, was excellent. Discussion
Critical ischaemia is much less common in the upper limb than in the lower limb, accounting for only 5% of peripheral vascular cases1, yet there are many causes. Diagnosis requires careful clinical and radiological assessmentl"2'6-'0 but, unlike the lower limb, the role of non-invasive methods in diagnosis is not well established. Clinical evaluation should include a history of accidental or occupational trauma; sudden ischaemia in the presence of atrial fibrillation suggests embolization. A significant number of patients with a connective tissue disorder will present with systemic symptoms. These may be local, for example aching in the shoulder girdle due to subclavian arteritis, or distal, due to the effects of ischaemia. Non-invasive laboratory studies are a useful adjunct to confirm clinical assessment, but arteriography7 remains the 'gold standard'. Doppler ultrasound and digital arterial pressure recordings confirm the degree of ischaemia and are useful to monitor change, but they do not demonstrate the cause of the ischaemia. For this, total extremity arteriography, sometimes including magnification, subtraction and cryodynamic techniques", may all be useful. Porter and his colleagues have reported the use of digital plethysmography to replace arteriography 'unless a surgically correctable lesion is suspected' 12, but this begs the question of how that suspicion would be aroused unless the vascular anatomy can be shown. Most emboli to the upper limb present with classical symptoms'3. They account for only 10-15% of all peripheral emboli'4"15, but the outcome is better than in the lower limb'6. Success in treatment depends on early diagnosis and anticoagulation'3. Embolectomy
Table 5. Thoracic outlet syndrome (four females)
Diagnosis
Arteriography
Treatment
Fibrous band Cervical rib, subclavian ulcer, distal emboli Bilateral cervical ribs Atrial fibrillation and cervical rib
Compression Proximal lesion and distal occlusions
Division of band Excision of rib, endarterectomy and sympathectomy Excision of ribs Embolectomy, thrombolysis, resection of rib, subclavian and brachial embolectomy
Bilateral compression Embolus, cervical rib stenosis and debris at elbow
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Journal of the Royal Society of Medicine Volume 85 May 1992
from an antecubital approach can be expected to produce a good result within the first 12 hours, as may be seen in these 12 patients, and there is a place for delayed surgery (up to five days) in those with adequate collateral vessels17. Anticoagulation is usually recommended to counter the risks of further emboli which may threaten up to a third of the patients6 and is associated with a high mortality. Both early and late surgery have been shown to be superior to anticoagulation alone'8. Arteriography was not required in these 12 classically-presenting patients but was undertaken in the patient who presented with a 'stroke in evolution', as well as an ischaemic arm; when clot had been demonstrated in both subclavian and common carotid arteries, she was managed by anticoagulation alone. While arteriography is not essential for the management of classical emboli, other symptoms require arteriographic diagnosis. Several names have been given to vasculitis affecting large vessels19, 'pulseless disease', Takayasu's disease or brachio-cephalic arteritis20. Both the aorta and its branches may be affected, including the renal artery21. The cause is unknown but an association with HLA-BW52 in Japan22, and MB3-DR4 histocompatibility antigens in the USA23, has been described. Large peripheral arteries may also be involved in patients with giant cell arteritis2A, which results in thickening due to proliferation of connective tissue, and an inflammatory cell infiltrate with multinucleate giant cells. The internal elastic lamina is disrupted and medial fibrosis and intimal damage lead to thrombosis, aneurysm and dissection. Symptoms result both from the local effects of inflammation, such as an aching shoulder, or from regional effects due to arm ischaemia. Angiographic signs include multiple long strictures3 which may improve with steroids. Surgery is reserved for the relief of severe obstruction25 26. Surgical procedures for unrelieved obstruction have been reviewed recently19, but the results are poor20 when compared to those for occlusive disease due to atheroma25. The value of complete arteriography from the thoracic outlet to the finger-tips is emphasized, since lesions may be shown at several sites20. The poor long-term results of sympathectomy for vasospastic symptoms, with a relapse rate of 77% from 1 to 7 years27'28, have restricted its use here to severe digital ischaemia in those in whom the obstruction has been fixed despite intra-arterial tolazoline. Porter12 has suggested that all of these patients have occult systemic disease. Of the 16 patients in this series who suffered small vessel arteritis, ten were shown to have an underlying connective tissue disorder. Porter and his colleagues have also reviewed the medical treatment of Raynaud's syndrome, confirming that treatment is less effective when fixed digital occlusions are shown, for example, by cryodynamic imaging. Treatment with prostaglandins29, the fibrinolytic-stimulating drug, stanazolol30, and plasmaphoresis31, have also been tried, but long-term benefit has not been proved. In this series, four of the six patients with idiopathic Raynaud's syndrome and fixed blocks responded well to transaxillary sympathectomy. Those with known underlying connective tissue disorders were also treated with steroids and azathioprine (2), with some improvement. One patient required digital amputation. The management of direct trauma has been well documented7'32, and five of the seven cases in this
series were successfully managed by local repair. Techniques used were resection and end-to-end anastomosis, thrombectomy, vein patch and repair of intimal dissection. Only one patient with direct arterial trauma needed arteriography, due to the late presentation of a long occlusion after cardiac catheterization. He underwent thrombectomy, with repair of the damaged vessel wall, because of disabling arm claudication, which is known to follow such injuries in up to 70% of patients, particularly if wrist pressure indices are reduced to half on exercise33 3. Conservative treatment alone will, however, usually be sufficient to prevent limb loss3. Paraesthesiae may persist, despite arterial repair, due to ischaemic nerve damage33. The problem of arterial injury remote from the site of trauma4 may easily be overlooked, even in comprehensive reviews, and presents significant difficulty in diagnosis. Of the two patients described here, one had a dislocated shoulder with a closed traction injury to the root of the neck. Arteriography showed that the subclavian artery was occluded but there was no bleeding and a good collateral circulation was seen; he was, therefore, managed conservatively. Such lesions may present late35, and successful conservative treatment depends on safe, early heparinization4. In the other case, arteriography demonstrated the lesion remote from the site of bony fracture, thus avoiding fruitless blind exploration. Atherosclerosis is generally more common in men36, but in the upper limb more women than men are affected; in this series, five ofthe six patients were female. The surgical treatment is well described'9, including endarterectomy and bypass. Extra-thoracic bypass is preferred, since this is safer than intrathoracic procedures37. Sympathectomy may be helpful when reconstruction is not practicable19. Vascular complications may develop in 10-20% of patients with thoracic outlet syndrome19. Compression of the subclavian artery between the first rib, the scalenus anterior muscle and a cervical rib may result in medial degeneration, with intimal hyperplasia, stenosis and post-stenotic dilatation. Distal embolization causes progressive digital ischaemia. Full arteriography should be performed and, if negative, should be repeated. This was necessary in one of these patients before the source of the emboli could be identified. On-table arteriography has been used, but the results should be interpreted with caution due to the frequency of spasm in the upper limb vessels. When the arteriogram is negative and there is a high index of suspicion9, blind exploration has been advised, but surgical access is difficult and every effort must be made to show the lesion preoperatively. Treatment ofthe proximal lesion and resection ofthe band is helpful in preventing further emboli9, but distal blocks are more difficult, as anastomosis between digital vessels is very limited. Sympathectomy may help to improve viability and control pain. Two patients were placed in the miscellaneous group. The first showed the value of axillo-axillary bypass for the ischaemic post-radiation stricture, when this simple procedure can be carried out while avoiding the irradiated field38. The second patient, who developed thrombosis of the vessels of her left arm, due to DIC, was diagnosed late due to the effects of shock on all her limbs. It was only on resuscitation that the diagnosis of local thrombosis in one limb was made.
Journal of the Royal Society of Medicine Volume 85 May 1992
This review has confirmed that, with the exception of classical emboli and direct open trauma, all patients with critical arm ischaemia require total limb arteriography. Duplex ultrasound scanning and pressure studies are useful and might even replace arteriographic diagnosis in the leg39. However, difficulties in Doppler examination of upper limb vessels and the wide spectrum of pathology responsible for ischaemia of the arm, suggest that arteriography is unlikely to be replaced by non-invasive methods in the foreseeable future. Fifty-seven patients with critical upper limb ischaemia were treated in a community hospital, serving a population of 200 000 people, over a period of nine years. Although uncommon, critical upper limb ischaemia remains a challenging problem with a diverse aetiology. To identify t-he cause and to plan and execute treatment, total limb arteriography should be performed in allpatients except those who present with obvious direct trauma and classical systemic embolism. Digital subtraction angiography, pressure studies and Duplex scanning may be helpful but cannot replace arteriography. References 1 Welling RE, Cranley JJ, Krause RJ, Hafner CD. Obliterative arterial disease of the upper extremity. Arch Surg 1981;116:1593-5 2 McNamara MF, Takaki HS, Yao JST, Bergan JJ. A systemic approach to severe hand ischaemia. Surgery 1978;83:1-11 3 Sano K, Aiba T, Saito I. Angiography in pulseless disease. Radiology 1970;94:69-74 4 Yanni D, Wetzig NR, Giddings AEB. Remote arterial injury; another cause of spunous'arterial spasm. J Cardiovasc Surg 1989;30:948-50 5 Walker WJ, Giddings AEB. A protocol for the safe treatment of acute lower limb ischaemiawith intra-arterial streptokinase and surgery. Br JSurg 1988;75:1189-92 6 Ricotta JJ, Scudder PA, McAndrew JA, DeWeese JA, May AG. Management of acute ischaemia of the upper extremity. Am J Surg, 1983;145:661-6 7 Jarrett F, Hirsch SA.' Current diagnosis and management of upper extremity ischaemia. Surg Ann 1984; 15:207-28 8 Schmidt FE, Hewitt RL. Severe upper limb ischaemia. Arch Surg 1980;115:1188-91 9 Whelan TJ. Management of vascular disease of the upper extremity. Surg Clin North Am 1982;62:373-88 10 Keenan JP, Robbs JV. The ischaemic hand and upper limb - a diagnostic and therapeutic dilemma. S Afr J Surg 1985;23:11-14 11 Rosch J, Porter JM, Gralino BJ. Cryodynamic hand angiography in the diagnosis and management of Raynaud's syndrome. Circulation 1977;55:807-14 12 Porter JM, Rivers SP, Anderson CJ, Bauer GM. Evaluation and management of patients with Raynaud's syndrome. Am J Surg 1981;142:183-9 13 Kaar G, Broe PJ, Bouchier-Hayes DJ. Upper limb emboli. J Cardiovasc Surg 1989;30:165-8 14 Hight DW, Tilney NL, Crouch NP. Changing clinical trends in patients with peripheral arterial emboli. Surgery 1976;79:172-6 15 Satiani B, Gross WS, Evans WE. Improved limb salvage after arterial embolectomy. Ann Surg 1978;188: 153-7 16 Stonebridge PA, Clason AE, Duncan AJ, Nolan B,
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17 Jarrett F, Dacumos GC, Crummy AB, Detmer DE, Belzer FO. Late appearance of arterial emboli: diagnosis and management. Surgery 1979;86:898 18 Baird RJ, Lajos TZ. Emboli to the arm. Ann Surg 1964;160:905-9 19 Williams SJ. Chronic upper extremity ischaemia: current concepts in management. Surg Clin North Am 1986;66:355-75 20 Cohen A, Manion WC, Spencer FC, et aL Occlusive lesions ofthe great vessels ofthe aortic arch. Arch Surg 1962;84:628-42 21 Sise MJ, Counihan CM, Shackford SR, Rowley WR. The clinical spectrum of Takayasu's arteritis. Surgery 1988;104:905-10 22 Isohisa I, Numano F, Maezawa H, Sasazuki T. HLABW52 in Takayasu's disease. Tissue Antigens 1978; 12:246-8 23 Volkman DJ, Mann DL, Fauci AS. Association between Takayasu's arteritis and a B-cell allo-antigen in North Americans. N Engl J Med 1982;306:464-5 24 Klein RG, Hunder CG, Stanson AW, Sheps SG. Large artery involvement in giant-cell (temporal) arteritis. Ann Intern Med 1975;83:806-12 25 McCarthy WJ, Flinn WR, Yao JST, Williams LR, Bergan JJ. Result of bypass grafting for upper limb ischaemia. J Vasc Surg 1986;3:741-6 26 Joyce JW. The giant-cell arteritides: diagnosis and the role of surgery. J Vasc Surg 1986;3:827-33 27 Hall XV, Hillstad LK. Raynaud's phenomenon treated with sympathectomy: a follow-up study. Angiology 1960;11:186-9 28 van de Wal HJCM, Skotnicki SH, Wijn PFF, Lacquet LK. Thoracic sympathectomy as a therapy for upper extremity ischaemia - a long-term follow-up study. Thorac Cardiovasc Surg 1985;33:181-7 29 Clifford PC, Martin MFR, Shedden EJ, Kirby JD, Baird RN, Dieppe PA. Treatment of vasospastic disease with prostaglandin E1. BMJ 1980;ii:1031-4 30 Jarrett PEM, Morland M, Browse NL. Treatment of Raynaud's phenomenon by fibrinolytic enhancement. BMJ 1978;ii:523-5 31 Talpos G, White JM, Horrocks M, Cotton LT. Plasmaphoresis in Raynaud's disease. Lancet 1978;i:416-18 32 Blacklay PF, Duggan E, Wood RFM. Vascular trauma. Br J Surg 1987;74:1077-83 33 Karmody AM, Lempert N, Jarmolych J. The pathology of post-catheterisation brachial artery occlusion. J Surg Res 1976;20:601-4 34 rammarher ER, Eikelboom BC, van Lier HJJ, Skotnicki SH, Wijn PFF. Brachial artery lesions after cardiac catheterisation. Eur J Vasc Surg 1988;2:145-9 35 Stanton PE(Jr), Brown R, Rosenthal D, Clark M, Lamis PA. External iliac artery occlusion by bicycle handle injury. J Cardiovasc Surg 1986;27:728-30 36 Gordon RD, Garrett HE. Atheromatous and aneurysmal disease of upper extremity arteries. In: Rutherford RB, ed. Vascular surgery. Philadelphia: WB Saunders Co, 1984:688-93 37 Crawford ES, DeBakey ME, Morris GC, et al. Surgical treatment ofocclusion ofthe innominate common carotid and subclavian arteries: a 10 year experience. Surgery
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(Accepted 14 August 1991)
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